A big part of our job at St. Joseph’s Health Centre is minimizing the pain experienced by patients during their hospital stay. This pain may be due to a medical condition or a surgical procedure – and it typically requires the use of some very strong drugs.
“When it comes to developing a pain management plan, opioids are often used in conjunction with other medications,” says Jill Campbell, a Nurse Practitioner on the Acute Pain Service, here at St. Joe’s. “Opioids can be used to treat moderate to severe acute pain, as well as chronic non-cancer pain, cancer pain, and pain in the palliative care setting.”
One of our main objectives at St. Joe’s is #Putting Patients First, and we’ve been making numerous improvements over the past several years to ensure these powerful drugs will help, not harm, our patients.
Opioids – also referred to as narcotics – include drugs such as morphine, hydromorphone and oxycodone, which all have different potencies.
These are the same opioid drugs identified by national agencies such as the Institute for Safe Medication Practice as requiring special care and attention during preparation and administration to patients.
Campbell, along with other interdisciplinary members of the St. Joe’s #High Risk Narcotics Working Group, evaluated the way these drugs are stored, accessed, prepared and distributed by staff members – to ensure the whole sequence leads to a safe result for patients in our care.
The team’s efforts led to the design of hospital-wide standardized narcotics cupboards with a colour-coded labeling system.
The High Risk Narcotics Working Group’s chair, Michael Heffer – who is also our Director of Pharmacy and Interprofessional Practice – says the team worked collaboratively with patient care managers to make improvements.
“We looked at all the concentrations of narcotics available in our organization, and what ones were available for nurses to select to prepare narcotics on the floor, and we removed all of the high-potency, high-concentration narcotics,” he explains.
So far, feedback from staff members about the new system has been positive.
Heffer adds that if a patient ever did need a high-concentration opioid, it would be dispensed from the pharmacy as a patient-specific dose and would only be available in the care unit for the period of time the patient needed the medication.
Another development is a tailoring of the narcotic record sign-out sheets for each unit.
“Surgery is different from Medicine, which is different from Mental Health,” notes Heffer. “So we worked with the patient care managers on each floor to come up with a tailored form that contained only those narcotics used on the unit. The resulting narcotic record was less cluttered with larger cells for clear documentation of the medication name, dose administered and required signatures.”
The organization has also invested in smart pumps for administration of IV medications, which feature pre-set limits for infusion rates that help ensure appropriate dosing.
“Let’s say a morphine infusion is supposed to run at 2 milligrams per hour. Having a smart pump means that when a nurse goes to program the IV pump, they can select morphine from a menu on a screen and the nurse will be prompted if they selects a dose outside of the normal range,” explains Heffer.
These practical initiatives, coupled with an educational component, are making a quantifiable positive impact in the reduction of safety errors when it comes to the use of opioids – meaning our patients are increasingly safer within our care.
“The initiatives are working,” says Heffer. “It’s very clear.”
There are several reasons why the High Risk Narcotics Working Group pushed forward these strategies. The first reason is in the group’s name: these drugs present very high risks, despite their widespread use.
Opioids are chemical drugs with a painkilling effect, and if used improperly, can lead to dangerous overdoses, allergic reactions, and even death.
According to Campbell, the busy environment of a hospital means checks and balances like the ones we have put in place are crucial to ensure the right amount of the right drug is given to each patient.
“The way drugs have been named by pharmaceutical companies, they sound very similar, like morphine versus hydromorphone,” Campbell adds. “But hydromorphone is five to seven times stronger than morphine. If you substitute hydromorphone for morphine, you could have a very significant overdose.”
Heffer says we have to pay special attention to opioid use here at St. Joe’s because of the large population of seniors in our care.
“They’re more sensitive to the effects of opioids,” he explains. “You have to look at a 180 pound, 40 year old adult versus a frail, 79 year old, 120 pound elderly person, who will be much more sensitive to smaller doses.”
Overall, the goal here at St. Joe’s is to ensure our patients, regardless of their age or medical history, receive safe pain management in our care. That means we’ll be continually implementing the strategies of the High Risk Narcotics Working Group to ensure opioids are used always safely and effectively.
“They are safe to use if they’re used as prescribed,” says Campbell. “That’s the bottom line.”
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